Improving Assessment and Learning Environments for Graduate Medical Trainees to Advance Healthcare Language Equity

Abstract

Language-appropriate care is critical for equitable, high-quality health care, but educational standards to assure graduate medical trainees are prepared to give such care are lacking. Detailed guidance for graduate medical education is provided by the Accreditation Council for Graduate Medical Education through the following: (1) an assessment framework for competencies, subcompetencies, and milestones for trainees and (2) the Clinical Learning Environment Review (CLER) Pathways for assessment of trainees’ learning environments. These tools do not include a robust framework to evaluate trainees’ abilities to offer language-appropriate care. They also do not address the learning environment’s potential to support such care. A multidisciplinary group of linguistic, medical, and educational experts drafted a new subcompetency with milestones and an expanded CLER Pathway to highlight the importance of equitable care for patients who prefer languages other than English. These resources offer residency and fellowship programs tools to guide assessment, curriculum development, and learning-environment improvements related to language-appropriate care. Recognizing that programs have unique needs and resources, we propose a range of initial actions to address language equity. A focus on language diversity in the learning environment can have a broad and lasting impact on care quality, patient safety, and health equity.

BACKGROUND

Language-appropriate care is critical for equitable, high-quality health care.^{1, 2} In the USA, the population speaking a language other than English is growing,³ surpassing 67 million in 2019.⁴ Over one-third of these individuals speak English less than “very well.”⁴ Federal regulations mandate equal provision of healthcare services regardless of language,⁵ and research demonstrates an association between non-English language preference and health disparities, emphasizing language as an important social determinant of health.^{2, 6–9}

Language-appropriate care improves healthcare communication, utilization, and outcomes.^{1, 2, 10} This can be achieved either in partnership with a qualified healthcare interpreter (interpreter-mediated care) or by an appropriately trained and qualified bilingual clinician (language-concordant care).¹¹ Despite existing guidance regarding healthcare interpreter qualifications,¹¹ the skills needed for bilingual clinicians to safely and effectively provide language-concordant care have not been clearly defined. Furthermore, language abilities should not be considered in isolation, but rather as part of a clinician's patient-centered communication skillset that includes navigating formality in communication, delivering sensitive information, recognizing culturally acceptable politeness norms, and respecting dialect or variation within a given language.

Graduate medical trainees (i.e., medical residents and fellows), the frontline clinicians in many major healthcare systems, commonly experience language discordance with patients.¹² Residents often underutilize language services,¹³ risking patient safety¹⁴ and potentially forming career-long habits that normalize linguistically inappropriate care.¹³ Out of perceived necessity, trainees may opt to use limited non-English language skills with patients without having their language proficiency formally assessed.¹³ This common practice places patients at risk of medical errors and inequitable care.^{12, 15–17} A lack of institutional support from hospitals, clinics, and health systems can also hinder trainees’ ability to provide linguistically and culturally appropriate care.^{18, 19} Conversely, interventions to formally teach and assess physician language proficiency can enhance trainees’ cross-cultural communication skills²⁰ and awareness of their language skills²¹ and limitations.²²

The Accreditation Council for Graduate Medical Education (ACGME) framework of competencies, subcompetencies, and milestones for assessing trainees includes general communication principles, but current subcompetencies do not explicitly address trainees’ skills in providing language-appropriate care for patients who prefer non-English languages. Similarly, the ACGME Clinical Learning Environment Review (CLER) Pathways to Excellence²³ includes cultural awareness within expectations for training programs but lacks guidance related to language support. To address these gaps, we propose a new language-appropriate care subcompetency and revisions to the existing CLER Pathways to Excellence.

APPROACH

We assembled an expert panel consisting of a diverse group of language and medical professionals, including GME program leaders, linguists, interpreters, researchers, language instructors, and physicians from multiple specialties. We recruited members via the National Association of Medical Spanish (NAMS), a national organization working to create standardized, evidence-based approaches to teaching and assessing medical Spanish.²⁴ Languages represented among the experts included English, Farsi, French, Gujarati, Hindi, Indonesian, Italian, Kewa, Mandarin, Marathi, Portuguese, Russian, Spanish, and Tok Pisin. Participants’ lived experiences and practice sites spanned all US regions (including both urban and rural environments), as well as several international locations. The resulting 13-member NAMS GME Subgroup, established in June 2020, met on a monthly basis for 18 months (4–12 participants per meeting). We assessed the need for a new language-appropriate care subcompetency and then conducted a modified Delphi process²⁵ to create and revise drafts of (1) a trainee subcompetency with milestones related to language-appropriate care and (2) additional wording for an existing CLER Pathway related to healthcare quality. The initial Delphi round focused on idea generation and subsequent rounds focused on review and feedback until consensus was reached (defined as full agreement among all participants that any edits/comments had been adequately addressed). The co-chairs presented drafts to the NAMS Board of Directors for feedback and approval, then to stakeholders at the ACGME for input and alignment with milestone development guidelines.

Existing Frameworks and Proposed Assessment Tools

Core Competencies and Milestones

The ACGME Milestones framework provides a standardized approach to describe the developmental progression of knowledge and skills gained through training. The framework is competency-based, detailing outcomes expected for a physician-in-training ready to enter independent practice. Six core competencies, applying to trainees in all medical fields, provide an overarching structure: practice-based learning and improvement, patient care and procedural skills, systems-based practice, medical knowledge, interpersonal and communication skills, and professionalism. Each of the > 100 medical specialties has developed specific subcompetencies, and the most recent version of the milestones (2.0) includes a core set of “harmonized milestones” for use by all specialities.^26–29 Each subcompetency contains a series of milestones characteristic of 5 trainee performance levels described in the Dreyfus Model of Knowledge Development,³⁰ ranging from novice to expert. Level 4 (“proficient”) is the target for a graduating trainee, and level 5 (“expert”) is aspirational. Residents are evaluated bianually throughout training to track developmental growth and improvement. Multiple assessment modalities may be used, including direct faculty observation, multi-source/interdisciplinary feedback, in-training exams, audit and performance data, simulation, case or procedural logs, and patient experience surveys. For the harmonized milestones, supplemental guides provide additional information regarding the intent of each milestone and additional guidance on how to assess trainees.

Proposed Language-Appropriate Care Subcompetency

To assess the need for a subcompetency, the expert panel first reviewed existing subcompetency sets for 5 specialties (internal medicine, family medicine, pediatrics, emergency medicine, and general surgery) to examine existing language-related milestones.³¹ Although occasional milestones within communication subcompetencies mentioned cultural and linguistic diversity, no specialty offered a subcompetency with progressive trainee milestones related to language-appropriate care.

To address this gap, we propose a new subcompetency entitled, “Provide language-appropriate care for patients who prefer languages other than English” under the “Interpersonal and Communication Skills” core competency (Table 1). This subcompetency applies to trainees across specialties. It describes fundamental skills for providing linguistically and culturally appropriate care: (1) centering patient language preferences and culture, (2) using communication supports to bridge language differences, and (3) assuring clear communication (confirming clinician and patient understanding). The subcompetency highlights the need for programs to target training in these areas and the importance of partnership with qualified healthcare interpreters. Also, it addresses qualifications for bilingual trainees wanting to provide language-concordant care in a non-English language without an interpreter.

Table 1.

Proposed New Graduate Medical Education Subcompetency with Milestones: “Provide Language-Appropriate Care for Patients Who Prefer Languages Other than English.”

Thread	Level 1 (Novice)	Level 2 (Advanced Beginner)	Level 3 (Competent)	Level 4 (Proficient)	Level 5 (Expert)
Centering patient language preferences and culture	Participates in discussion regarding patient language preference	Identifies patient language preferences during clinical encounter	Identifies patient language preferences prior to clinical encounter	Demonstrates understanding of the interface between language and culture and its impact on health communication	Navigates dynamic needs related to language and culture in complex and high stakes encounters; supports and guides others in doing the same
Using communication supports to bridge language differences	Discusses the importance of trained, qualified interpreters	Identifies and engages interpreter services available through the institution	Collaborates with trained, qualified interpreters; uses own language skills when appropriate (if qualified by program or institution)	Supplements language-appropriate oral communication with written and/or visual information and resources appropriate for the patient’s language and culture	Advocates for systematic communication supports, including effective interpretation, translation, and qualified bilingual staff services
Assuring clear communication, confirming clinician and patient understanding	Attempts to use clear language that avoids medical jargon	Uses plain language in simple situations, confirms patient understanding through “yes/no” questions	Recognizes potential miscommunications; clarifies and negotiates meaning of unfamiliar terms or cultural concepts; consistently uses plain-language teach-back to confirm understanding	Adjusts conversation formality to meet individual patient needs; demonstrates cultural and linguistic humility by consistently confirming own understanding of patient’s perspectives	Uses advanced intercultural communication skills (e.g., makes complicated medical concepts easy to understand); teaches others the concepts and skills to assure clear communication and patient understanding

The Clinical Learning Environment Review Pathways

A GME program’s institutional context plays a fundamental role in the quality of education trainees receive and the quality of care they learn to provide. With this in mind, the ACGME established the CLER Pathways to Excellence program in 2012 as a framework to evaluate a program’s learning environment and to give feedback to GME and hospital leaders.²⁴ CLER Pathways Version 2.0, published in 2019, included six focus areas: Patient Safety, Health Care Quality, Teaming, Supervision, Well-being, and Professionalism. Each focus area includes multiple pathways containing properties that explain how trainees and faculty should interface with the clinical learning environment. Under the Health Care Quality focus area, Pathway 7 states that “[r]esidents, fellows, and faculty members deliver care that demonstrates cultural humility.” It further specifies that the clinical learning environment “provides residents, fellows, and faculty members continual training in cultural humility” and results in care that “includes the views of culturally diverse patient populations.”

We propose additions to the wording of the CLER Health Care Quality Pathway 7 to highlight the importance of language for quality and safety of care (Text Box 1). These modifications emphasize the role of language in providing equitable care for culturally and linguistically diverse patients, since language-appropriate care is associated with improvements in outcomes, quality of care, and patient safety.^{1, 2, 6, 7} The term “linguistic humility” refers to an approach that values all languages equally and centers on the patient’s preferred language rather than the system’s predominant language. It acknowledges the responsibility of the healthcare system to respect and provide linguistic support for patients who prefer non-English languages, recognizing that speakers of all languages deserve the same level of communication and care.

Text Box 1 Proposed language-related additions to the Clinical Learning Environment Review (CLER) Pathways to Excellence for graduate medical education. Proposed additions in bold text.

Health Care Quality 7: Residents, fellows, and faculty members deliver care that demonstrates cultural and linguistic humility

The clinical learning environment:

A. Provides residents, fellows, and faculty members continual training in cultural and linguistic humility relevant to the patient population served by the clinic site

B. Ensures that the clinical care team, including residents, fellows, and faculty members, delivers care that incorporates the views of culturally and linguistically diverse patient populations

C. Ensures that residents, fellows, and faculty members are knowledgeable and proficient in engaging available language support services

D. Provides a process for determining if residents, fellows, and faculty members are qualified to safely and effectively use languages other than English to provide clinical care

The suggested modifications emphasize the responsibility of a program, clinic, or hospital system to ensure that faculty and trainees receive sufficient training to provide language-appropriate care; that such care is patient-centered; and that they are aware of existing language support services and their appropriate use. Finally, the modifications reflect the importance of assuring bilingual physicians’ linguistic competency through formal qualification so that trainees and faculty do not use limited language skills to the detriment of quality and safety.

IMPLICATIONS

Adding a subcompetency and CLER Pathway content that addresses language-appropriate care signals to GME program faculty and trainees that language is an important factor for achieving safe, effective care in all specialties. This approach adds a layer of accountability in physician training that indexes language as an essential component to address disparities in health-care quality, as acknowledged by The Joint Commission,³² the Centers for Medicare and Medicaid Services,³³ the Department of Health and Human Services,³⁴ and the National Institutes of Health.³⁵

Program Actions and Outcomes

The proposed subcompetency and expanded CLER Pathway provide GME programs with a means to assess both trainees and the learning environment. To facilitate implementation, we recommend strategies for GME leaders to incorporate and evaluate the new subcompetency and CLER additions within their programs (Table 2). We also provide a Milestones Supplemental Guide (Appendix Table 3) and resources (Appendix Table 4) for evaluating language-appropriate care by trainees. This Supplemental Guide leaves room for residency programs to map the subcomptency to their curriculum and to contribute additional, individualized examples as relevant to their program and institution. Acknowledging that sites may vary in their language support services (e.g., medical interpretation or qualification processes for bilingual physicians), the aspirational goals in the expanded CLER Pathway can guide GME leaders in advocating for system-wide improvements. Because all healthcare organizations that receive federal funding, including Medicare and Medicaid, are required to provide meaningful access to language services,³⁶ specific guidance related to the clinical learning environment can help advance efforts to meet this requirement.

Table 2.

Proposed Strategies and Tactics to Implement the Language-Appropriate Care Graduate Medical Education Subcompetency and Clinical Learning Environment Review (CLER) Pathway 7 Additions

Strategy	Tactics
Identify program and institutional champions	▪ Create a diverse team representing learners, faculty, interpreters, and the sponsoring institution to guide the adoption and use of the subcompetency and expanded CLER Pathway 7
Integrate new subcompetency into existing assessment processes	▪ Promote awareness of the impact of language on health equity during trainee onboarding
	▪ Normalize the use of language support services
	▪ Promote formal, validated assessment of language skills
	▪ Longitudinally assess trainees using evidence-based tools (Appendix Table 4); faculty may benefit from collaboration with qualified bilingual staff and interpreters for feedback on trainee performance
	▪ Provide formative feedback based on results of longitudinal assessment at the semi-annual review along with the feedback given for other subcompetencies
Analyze programmatic and institutional gaps	▪ Identify gaps in milestone progression and their root causes
	▪ Using the expanded CLER Pathway 7, evaluate the institution’s support for the provision of culturally and linguistically appropriate care via key informant interviews with program and institutional leadership
Develop and implement an action plan	▪ Based on the gap analysis, implement an action plan with program leadership to improve milestone attainment
	▪ Use the expanded CLER Pathway 7 to shape the sponsoring institution’s priorities for language access, quality, and safety as they relate to health equity
Disseminate best practices	▪ Present programmatic and institutional wins at conferences and in medical literature
	▪ Develop replicable standards and processes for adoption by other institutions

Table 3.

Milestones supplemental guide for Language-Appropriate Care*

Language-Appropriate Care Subcompetency
Overall Intent: To provide safe and equitable care for patients who prefer languages other than English
Milestones	Examples
Level 1
• Participates in discussion regarding patient language preference	• Talks with supervising physician and other care team members about how to determine a patient’s oral and written language preferences
• Discusses the importance of trained, qualified interpreters	• Recognizes the risk of having the patient’s child interpret when the intake staff notes that the patient prefers Spanish
• Attempts to use clear language that avoids medical jargon	• Recognizes that plain language is important for effective patient communication and attempts to avoid complex or technical terminology
Level 2
• Identifies patient language preferences during clinical encounter	• Recognizes that a patient is having difficulty with English communication during a clinical encounter and discusses language assistance needs with the patient
• Identifies and engages interpreter services available through the institution	• Independently requests a qualified interpreter for a clinical encounter after language discordance has been identified
• Uses plain language in simple situations, confirms patient understanding through “yes/no” questions	• Tries to use terms such as “blood pressure medicine” instead of “antihypertensive” and “infection of the skin” instead of “impetigo”
	• Checks with the patient to confirm understanding by asking questions such as: “Did you understand why you need that medication?” or “Do you have any questions about your diagnosis?”
Level 3
• Identifies patient language preferences prior to clinical encounter	• Determines that a patient prefers Korean before a clinic visit by reviewing the electronic health record, speaking with the medical assistant, and respectfully confirming language assistance needs with the patient at the start of the visit
• Collaborates with trained, qualified interpreters; uses own language skills when appropriate (if qualified by program or institution)	• When possible, conducts a brief pre-session (1–2 min) with the interpreter prior to or at the start of the encounter to explain the clinical context for the upcoming interaction. Introduces the interpreter to the patient, positions the interpreter so that trainee and patient interact easily with each other, speaks directly to the patient, and allows interpretation after every one or two sentences
	• As a qualified bilingual trainee, confidently evaluates a patient with a routine problem in the trainee’s specialty but calls for a qualified interpreter when the patient unexpectedly brings up a new problem that is more complex or is outside of the trainee’s area of comfort
• Recognizes potential miscommunications; clarifies and negotiates meaning of unfamiliar terms or cultural concepts; consistently uses plain-language teach-back to confirm understanding	• Asks respectful questions for clarification when unsure what a patient means by a certain term or cultural health concept
	• Confirms patient understanding by asking questions such as, “I would like to make sure I explained myself clearly. Would you please repeat back to me what type of food or drink you should avoid while taking this medication?”
Level 4
• Demonstrates understanding of the interface between language and culture and its impact on health communication	• Ensures that a patient’s new diagnosis is explained using culturally relevant terms, analogies, and examples
	• Asks if a patient would like a relative, friend, or caregiver to be present for the discussion and checks for language needs of companions who will be present (recognizing that the role of family members and friends in communication and decision-making may vary)
• Supplements language-appropriate oral communication with written and/or visual information and resources appropriate for the patient’s language and culture	• After explaining a medication taper to a patient, uses available institutional or publicly available resources (ideally professionally translated) that include simple images illustrating how the medication dosing will change over time
• Adjusts conversation formality to meet individual patient needs; demonstrates cultural and linguistic humility by consistently confirming own understanding of patient’s perspectives	• Identifies a patient’s communication style and strives to match language use to that style, recognizing the strong role of culture in style differences. As needed, checks with patient and interpreter about the patient’s communication preferences
	• Restates a patient’s expressed belief about the cause of an illness and asks further questions to confirm understanding
Level 5
• Navigates dynamic needs related to language and culture in complex and high stakes encounters; supports and guides others in doing the same	• Discusses end-of-life decision-making, including identifying and discussing relevant cultural factors with a patient and multiple family members who have different language preferences (for example, a patient who prefers Urdu, the patient’s bilingual spouse, and their son who prefers English)
• Advocates for systematic communication supports, including effective interpretation, translation, and qualified bilingual staff services	• Recognizes a gap in interpreter services during peak hours of a clinical shift and advocates for system change to ensure equitable care for patients with non-English language preferences
	• Identifies that discharge instructions are not available in a particular language that is common in the institution’s patient population and that residents are using computer-based translation software to prepare patient instructions. Advocates for professional translation of routine discharge instructions in the service area’s most common languages in order to reduce risk of miscommunication and patient harm
	• Identifies the lack of a qualification process for bilingual staff and requests that the institution and training program provide formal assessment of clinicians’ non-English language skills
	• Provides a patient who has a difficult diagnosis and complicated treatment plan with complete but understandable explanations. Confirms explanations through teach-back, written materials with helpful images, and clear instructions on how to contact the care team throughout the care journey
• Uses advanced intercultural communication skills (e.g., makes complicated medical concepts easy to understand); teaches others the concepts and skills to assure clear communication and patient understanding	• Creates a toolkit for the clinic to help other staff and clinicians remember key skills such as teach-back and use of plain language with all patients regardless of language preference
Assessment models or tools	• Direct observation
	• Multisource feedback
	• Simulation
Curriculum mapping†
Resources	See Appendix Table 4

^*This table provides guidance and examples for the language-appropriate care subcompetency milestones. The table is not designed to indicate any specific requirements for each level. Instead, it provides examples of what a Clinical Competency Committee might expect to observe/assess for a trainee at each level. Individual programs may consider creating an individualized guide that includes institution/program-specific examples, assessment tools used by the program, and curricular components

^†Curriculum Mapping is intentionally left blank for internal program use since curricula will vary by graduate medical education program. Note: The table structure is adapted from the Accreditation Council for Graduate Medical Education’s Supplemental Guides including Family Medicine²² and Psychiatry²³

Table 4.

Resources to support the use of the language-appropriate care subcompetency and the expanded Clinical Learning Environment Review (CLER) Pathway 7 in graduate medical education programs

Centering Patient Language Preferences and Culture	Using communication supports to bridge language differences	Assuring clear communication, confirming understanding
Assessing and responding to language needs • The complexities of assessing language and interpreter preferences in pediatrics (Ragavan and Cowden, 2018)49 • Patient perspectives on the need for and barriers to professional medical interpretation (Brooks et al., 2016)52 • Conditions for communication between health care professionals and parents on a neonatal ward in the presence of language barriers (Patriksson et al., 2019)55 • Patients with limited English proficiency: TeamSTEPPS Curriculum 57 Staff training model from the Agency for Healthcare Research and Quality recognizing language needs and responding to them to improve safety	Medical Spanish best practices and core competencies • An overview of medical Spanish curricula in the United States (Hardin, 2015)50 • Medical Spanish standardization in U.S. medical schools: consensus statement from a multidisciplinary expert panel (Ortega et al., 2020)53	Teach back: training and assessment • Always use Teach back! training toolkit51 • teachback.org 54 • The 5Ts for Teach Back: an operational definition for teach-back training (Anderson et al., 2020) 56 • Development and implementation of a health literacy training program for medical residents (Kripalani et al., 2006)58
	Medical Spanish training models in the GME setting • Culture and language coaching for bilingual residents: the first 10 years of the CHiCoS model (Cowden et al., 2022)21 • Sí, tu puedes: an integrated Spanish language acquisition in residency utilizing personal instruction (Barr et al., 2018)37
	Partnering with interpreters: education and assessment • Communication with diverse patients: addressing culture and language (O’Toole et al., 2019)60 • Partnering with interpreter services: standardized patient cases to improve communication with LEP patients (Taylor et al., 2019)60 • Lost in Translation: an OSCE-based workshop for helping learners navigate a limited English proficiency patient encounter (Fune et al., 2021)61
		Patient perception of communication • The Hispanic Clinic for Pediatric Surgery: A model to improve parent-provider communication for Hispanic pediatric surgery patients (Jaramillo et al., 2016)59 Includes tool for measuring patient perception of communication • Comunicación y Habilidades Interpersonales scale (Ortega et al., 2021)47 Validated Spanish adaptation of the Communication and Interpersonal Skills scale
	Medical language proficiency assessment • The Kaiser Permanente Clinician Cultural and Linguistic Assessment initiative: research and development in patient-provider language concordance (CCLA) (Tang et al., 2011)38 Validated clinician language phone-based exam • ‘Does this doctor speak my language?’ Improving the characterization of physician non-English language skills (Diamond et al., 2012)40 Interagency Language Roundtable (ILR) scale for healthcare, a validated language proficiency self-assessment tool • Physician Language Observation Matrix (POLOM) (Diamond et al., 2022)41, 42 Instrument for trained raters to reliably assess medical student/physician oral proficiency during patient encounters

Professionalization of Language Use in Healthcare

A historical lack of standards for clinician use of non-English languages has led to a movement toward the “professionalization” of language use in healthcare. This movement includes healthcare systems and GME programs that have (1) implemented formal processes to assess professional proficiency in non-English languages and (2) set expectations for when faculty and trainees are allowed to use their non-English language skills to provide patient care.^{21, 37, 38} Such actions reflect the responsibility of healthcare systems and GME programs to provide guidance and standards for competency in a range of professional skills, including communication. Failure to provide standards for the clinical use of non-English languages English puts patients, clinicians, and organizations at risk.³⁹

The proposed language subcompetency adds to the repertoire of tools available to assess trainees’ skills in communicating with linguistically diverse populations and acknowledges that effective strategies will vary depending on both patient and clinician factors. For example, a multilingual resident may, in some contexts, and with patients who speak certain languages, be able to provide language-concordant care independently, and in other situations, may need to work with a qualified healthcare interpreter. While there is no current national standard for assessing a clinician’s ability to provide care in non-English languages, a validated oral proficiency test (the Clinician Cultural and Linguistic Assessment [CCLA]³⁸) and self-assessment tool (Interagency Language Roundtable [ILR] scale adapted for use in medicine^{39, 40}) have been used by healthcare systems and GME programs to qualify bilingual clinicians. More recently, the Physician Oral Language Observation Matrix (POLOM) has been developed and evaluated as a tool to assess medical student Spanish proficiency during standardized patient encounters.^{41, 42} In addition to oral proficiency tests, bilingual clinicians need to have strong self-assessment skills and a dedication to ongoing improvement and reassessment.

Next Steps

Evaluating resident physician milestones in language-appropriate care will open new possibilities in exploring the impact of these skills on clinical outcomes, processes of care, and patient safety. Adoption of the proposed subcompetency and the expanded CLER Pathway may enhance healthcare communication quality and efficiency for all patients regardless of language. For example, recognition and consideration of cultural influences, use of plain language, and confirmation of understanding through teach-back are useful for all patients, including those who speak English but experience low health literacy and other barriers when interacting with the healthcare system. Future studies could assess the impact of the proposed subcompetency on several outcomes, including resident well-being and feelings of belonging, process of care metrics in chronic disease, and diagnostic error for patients who prefer to communicate in languages other than English.

The field of language-appropriate medical education is rapidly expanding through ongoing educational efforts related to partnering with qualified interpreters,⁴³ intercultural communication,^{44, 45} and trainee language learning and assessment.^46–48 Next steps include implementing and evaluating the language-appropriate care subcompetency in a group of GME programs and gathering feedback from leaders, faculty, and trainees. We anticipate that inclusion of this subcompetency may prompt interest in enhancing resident preparedness to provide language-appropriate care. Educational strategies may include teaching residents how and when to request a qualified healthcare interpreter, offering medical language training or formal assessment for multilingual residents, and incorporating clinical cases involving patients with non-English language preferences in simulation activities, case conferences, or didactic sessions. After evaluation and refinement, the subcompetency may be suitable for inclusion in the cross-specialty “harmonized milestones” currently available from the ACGME, providing a universal expectation across all specialities. This new proposed standard—to train physicians to provide language-appropriate care—represents a fundamental step toward achieving equitable care for all patients.

Appendix

Tables 3 and 4

Declarations:

Prior Presentations:

None.

Disclaimers:

None.

Conflict of Interest:

P. Ortega receives textbook author royalties from Elsevier. L. Diamond receives royalties from a book she edited for Multilingual Matters. The Baylor University Spanish Scholarship Fund receives K. Hardin’s author royalties from Stipes Publishing. P. Ortega, L. Diamond, and K. Hardin serve on the board of directors of the National Association of Medical Spanish in an unpaid volunteer capacity. F. Martinez serves as a commissioner for the Certification Commission for Healthcare Interpreters in an unpaid volunteer capacity. The authors have no additional disclosures.